Effectiveness and Cost

There’s a growing sentiment that a solution to out of control medical costs might be to limit reimbursement of diagnostic and therapeutic procedures that are deemed to be of little or no effectiveness. I’ve written earlier that this is rationing of medical care in disguise. But let’s look at his issue in a little more detail.

To start, give Something’s Got to Give in Medicare Spending a read. It’s by Tyler Cowan an economist from George Mason University. As is typical in this field, he’s got the economic reality of federal healthcare funding down cold. He’s on less solid ground when he shifts to the medical half of the equation:

If we are willing to take comparative-effectiveness studies seriously, we could make significant cuts in Medicare costs right now. We could cut some reimbursement rates, limit coverage for some of the more speculative treatments, like some forms of knee and back surgery, and place more limits on end-of-life-care.

He realizes that this won’t happen, but the reasons he gives, while valid, leave out the most important reason why this type of rationing won’t work. What he doesn’t realize, and almost no one wishes to admit, is that much (perhaps most) of medical care lacks good evidence for its effectiveness.

Consider cancer treatment. Chemotherapy for treatment of solid tumors (this excludes leukemia and lymphomas) are of limited or no effectiveness. Are we willing to tell this to cancer patients and their families? While almost any doctor outside of oncology will concede the point in private, vanishingly few will say so in public. Mull the implications of this if you think it might be true. If we were to save money by limiting care it would have to include the big stuff – cancer, heart disease, diabetes. You can’t balance the medical budget with less back and knee surgery.

Next go to psychiatry. Most of what psychiatrists do lacks even the slimmest basis in science for its effectiveness. It is the very lack of good evidence supporting treatment in oncology and psychiatry that make them the two most important specialties in medicine. I’m not being facetious. The less we know about something the more we need an expert for its management. Before penicillin there was a medical specialty devoted to the treatment of syphilis. Once we had an effective treatment we no longer needed an expert for its management.

The public and the medical profession would no more forsake the treatment of important diseases no matter how ineffective than would the Rostovs forgo treating Natasha’s depression in War and Peace even though they, the patient, and the doctor all knew that the treatment was useless. I’ll post the entire scene later. It should be required reading for all. When people are sick something must be done. Whether it works is secondary. Note that Natasha’s doctor is paid in gold at the end of his visit. Everybody was satisfied with his appearance because something was done. Natasha eventually gets better on her own.

Cowan concludes his NY times piece on a pessimistic note: The most likely possibility is that the government will spend more on health care today, promise to realize savings tomorrow and never succeed in lowering costs. It is rare that governments successfully cut costs by first spending more money. “Rare” is an understatement.

Also consider that the AMA has come out against a national government run medical care scheme, hospitals are protesting President Obama’s proposed cuts in Medicare, as is the pharmaceutical industry. Meanwhile The Access to Medical Imaging Coalition is lobbying against plans to reduce the number of CTs and MRIs done. There are too many stakeholders who won’t give up any of their piece of the pie to allow real reform. Also how can anything intelligent survive passage through two houses of 535 politicians.

When your dog becomes unmanageable you take him to a professional trainer hoping that he can bring the beast under control. If the trainer fails euthanasia is the only remedy. The health care beast seem beyond management.

So is there any way out of this mess? Mancur Olson had one. The late economist posited that the only way to reform a really big system was to have it first collapse. Politics would prevent any other remedy. Collapse has the salutary effect of allowing you to start over. All the stakeholders start with nothing. I think that medical care in this country falls under this category – too big not too fail.

About Neil Kurtzman

Neil A Kurtzman MD is the Grover E Murray Professor Emeritus and University Distinguished Professor Emeritus, Department of Internal Medicine at Texas Tech University Health Sciences Center in Lubbock. He has combined careers in clinical medicine, education, basic research, and administration for more than 30 years.